BECK DEPRESSION INVENTORY

Instructions: This questionnaire consists of 21 groups of statements. Please read each group of statements carefully, and then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today. Choose the button beside the statement you have picked. If several statements in the group that seem to apply equally well, choose the highest number for that group.

Sadness*

0 - I do not feel sad

1 - I feel sad much of the time

2 - I am sad all of the time

3 - I am so sad or unhappy that I can't stand it

Pessimism*

0 - I am not discouraged about my future

1 - I feel more discouraged about my future than I used to be

2 - I do not expect things to work out for me

3 - I feel my future is hopeless and will only get worse

Past Failure*

0 - I do not feel like a failure

1 - I have failed more than I should have

2 - As I look back, I see a lot of failures

3 - I feel I am a total failure as a person

Loss of Pleasure*

0 - I get as much pleasure as I ever did from the things I enjoy

1 - I don't enjoy things as much as I used to

2 - I get very little pleasure from the things I used to enjoy

3 - I can't get any pleasure from the things I used to enjoy

Guilty Feelings*

0 - I don't feel particularly guilty

1 - I feel guilty over many things I have done or should have done

2 - I feel quite guilty most of the time

3 - I feel guilty all of the time

Punishment Feelings*

0 - I don't feel I am being punished

1 - I feel I may be punished

2 - I expect to be punished

3 - I feel I am being punished

Self-Dislike*

0 - I feel the same about myself as ever

1 - I have lost confidence in myself

2 - I am disappointed in myself

3 - I dislike myself

Self-Criticalness*

0 - I don't criticize or blame myself more than usual

1 - I am more critical of myself than I used to be

2 - I criticize myself for all of my faults

3 - I blame myself for everything bad that happens

Suicidal Thoughts or Wishes*

0 - I don't have any thoughts of killing myself

1 - I have thoughts of killing myself, but I would not carry them out

2 - I would like to kill myself

3 - I would kill myself if I had the chance

Crying*

0 - I don't cry anymore than I used to.

1 - I cry more than I used to

2 - I cry over every little thing

3 - I feel like crying, but I can't

Agitation*

0 - I am no more restless or wound up than usual

1 - I feel more restless or wound up than usual

2 - I am so restless or agitated that it's hard to stay still

3 - I am so restless or agitated that I have to keep moving or doing something

BECK ANXIETY INVENTORY

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by choosing the button next to the corresponding symptom.

Review of Systems

Check if you have ever experienced any of the conditions listed below. If you have please use the Details box to describe: Date(s) of the occurrence, duration of illness, symptoms, did you seek treatment, what was the treatment received, what was the result of treatment, treating physician's name, or if you did not seek treatment what was the outcome.

Please list any other disease or condition you may have that is not listed above.

This medical history questionnaire will be reviewed by qualified medical personnel of this agency’s staff. If the medical personnel have further questions, they may interview me personally or request that my therapist ask me more questions in greater detail. If the medical personnel are concerned that physical medical problems are partially causing my mental health problems or that I may have a physical illness that demands immediate treatment, they will refer me to an appropriate medical specialist for further diagnosis and treatment. I am responsible for attending to my own medical conditions and following up on any recommendations made. This agency’s recommendations will be based upon the information supplied by me on this questionnaire only, as of this date. Other information not supplied may significantly alter the recommendations made for follow-up referrals. I have read and understand this statement regarding my responsibilities and the limitations of follow-up referrals made based upon the information I supplied

CONFIDENTIALITY POLICY AND CONSENT TO TREAT

I have read and agree to the Confidentiality Policy and Consent to Treat

Patient/Custodial Parent/Guardian Signature:*

Today's Date*

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

By signing below, I acknowledge that I have received a copy of the Notice of Privacy Practices. The notice describes how my health information may be used or disclosed. I understand that I should read it carefully. I am aware that the notice may be changed at any time and that i may obtain a revised copy of the notice at the clinic location where I receive healthcare services.
Click here to read the Notice of Privacy Practices prior to signing below.

Patient/ Custodial Parent/ Guardian Signature:*

Today's Date*

Are you filling this form out for someone else?*

Such as a child or someone in your guardianship

Yes

No

Name*

FirstLast

Relationship to Patient:*

Do you live at the same address as the patient?*

Yes

No

Your Address:*

Street AddressCityStateZIP Code

Phone:*

RELEASE OF INFORMATION FOR REFERRING PROVIDER

I authorize the provider to contact, or confirm with the referring provider an appointment made for follow-up, as well as general information pertaining to psychological and emotional function if indicated. I understand detailed clinical information will not be released without my written consent.

Decline

Referring Provider Name:*

Patient/Custodial Parent/Guardian Signature:*

Today's Date*

EMAIL AUTHORIZATION

By providing my email address below, I hereby agree to allow the provider to contact me by email. I understand that my email will not be shared with any outside companies.

Decline

Email address:*

Patient/ Custodial Parent/ Guardian Signature:*

Today's Date*

RELEASE OF SCHOOL EXCUSE

I authorize the provider to send a school excuse to my child's school.

Phone number for Mental Health, Customer Service, or Eligibility/Benefits:*

ID/Policy #:*

Group/Plan/Division #:

Employer (if applicable):

SECONDARY INSURANCE INFORMATION

Do you have secondary insurance?*

Yes

No

Patient's Relationship to Policy Holder:*

Self

Spouse

Child

Step-Child

Policy Holder's Name:*

FirstMiddleLast

Does the patient live at the same address as the Policy Holder?*

Yes

No

Policy Holder's Address:*

Street AddressAddress Line 2CityStateZIP Code

Policy Holder's Date of Birth:*

MM

DD

YYYY

Policy Holder's SSN:

Secondary Insurance Company:

Aetna

Ambetter

AMCO / Stratose HFN

Blue Advantage

Blue Cross Blue Shield

Cigna - OUT OF NETWORK

Coventry

Employer's Health Coalition (EHC)

Government Employees Health Administration (GEHA) - OUT OF NETWORK

Health Advantage

Municipal Health Benefit Fund

Qualchoice

UMR

UMR University of Arkansas - OUT OF NETWORK

United Healthcare - OUT OF NETWORK

Phone number for Mental Health, Customer Service, or Eligibility/Benefits:*

ID/Policy #:*

Group/Plan/Division #:

Employer (if applicable):

AUTHORIZATION FOR INSURANCE PAYMENT

My signature below indicates that I agree to authorize payment of insurance benefits to the service provider, authorize the release of any information necessary to process insurance claims, and accept payment responsibility of the portion of the bill which insurance does not cover.

RELEASE TO DISCUSS FINANCIAL INFORMATION

We cannot share information about your financial account with anyone unless we have your written authorization. The exceptions to this are biological parents of a minor, those listed as legal guardians of adults, or anyone listed below.

Decline

I hereby authorize the provider and/or staff to disclose financial information with the following person(s):*

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